From the Guidelines
Hormone replacement therapy (HRT) should be temporarily discontinued in someone with endometrial thickening while the cause is investigated, especially if the thickness exceeds 5mm in postmenopausal women, as unopposed estrogen can stimulate endometrial growth, potentially increasing the risk of hyperplasia or cancer 1.
Key Considerations
- The investigation typically involves endometrial biopsy or hysteroscopy to rule out hyperplasia or malignancy.
- If the thickening is due to unopposed estrogen, adding a progestogen component to the regimen may be appropriate rather than stopping HRT completely.
- For women already on combined HRT who develop endometrial thickening, a different approach to hormone therapy might be needed after evaluation.
Rationale
- Unopposed estrogen increases the risk for endometrial cancer, with a relative risk of 2.3 (95% CI, 2.1 to 2.5) for users compared with nonusers, and risks increase with increasing duration of use 1.
- Combined estrogen-progestin regimens have shown a decreased risk for endometrial cancer (RR, 0.4; 95% CI, 0.2 to 0.6) compared with nonusers, but case-control studies have shown an increase in risk (odds ratio [OR], 1.8; 95% CI, 1.1 to 3.1) 1.
Management
- Once malignancy has been ruled out and the appropriate adjustments to the HRT regimen have been made, many women can safely resume hormone therapy under close monitoring with regular ultrasound assessments.
- The decision to stop or modify HRT should be individualized, taking into account the woman's symptoms, medical history, and preferences.
From the Research
Stopping HRT in Someone with Endometrial Thickening
- The decision to stop Hormone Replacement Therapy (HRT) in someone with endometrial thickening depends on various factors, including the severity of the thickening and the presence of symptoms 2.
- Endometrial hyperplasia, a condition characterized by excessive thickening of the endometrium, can be caused by unopposed estrogen therapy, which is often used in HRT 3, 4.
- Studies have shown that the addition of progestogen to estrogen therapy can reduce the risk of endometrial hyperplasia and improve adherence to therapy 3, 5.
- However, the optimal management of endometrial hyperplasia, including the decision to stop HRT, is still debated and requires careful consideration of individual patient factors 4, 6.
- In general, women with endometrial thickening or hyperplasia should be closely monitored and managed by a healthcare provider to prevent the development of endometrial cancer 6.
Factors to Consider
- The severity of endometrial thickening or hyperplasia
- The presence of symptoms, such as abnormal uterine bleeding
- The patient's medical history and risk factors for endometrial cancer
- The type and duration of HRT used
- The patient's desire for fertility-sparing treatment options
Treatment Options
- Hysterectomy: a definitive and curative treatment for endometrial hyperplasia, especially in cases with atypia or cancer 4, 6.
- Progestin therapy: can be used to treat endometrial hyperplasia and reduce the risk of cancer 3, 5.
- Close monitoring: regular follow-up with a healthcare provider to monitor endometrial thickness and detect any changes or abnormalities 2, 6.